A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Sends the incident report to the ethics committee

Lists names of witnesses to the fall in the nurses' notes

Includes the client's account of the fall in the incident report

Documents in the client's record that an incident report was filed

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

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Correct Answer is D

Explanation

Choice A reason: Accompanying a client who just had a wound debridement to physical therapy is not a task that the nurse should assign to the LPN, as it requires the nurse to monitor the client's vital signs, wound status, and pain level. The nurse should accompany the client and delegate other tasks to the LPN or the assistive personnel.

Choice B reason: Providing postmortem care for a client who has just died is not a task that the nurse should assign to the LPN, as it requires the nurse to verify the death, notify the provider and the family, and document the care. The nurse should provide postmortem care and delegate other tasks to the LPN or the assistive personnel.

Choice C reason: Obtaining a urine specimen from an older adult client is not a task that the nurse should assign to the LPN, as it is a basic skill that the assistive personnel can perform. The nurse should assign this task to the assistive personnel and supervise their work.

Choice D reason: Reinforcing dietary teaching with a client who has heart disease is a task that the nurse should assign to the LPN, as it is within the LPN's scope of practice to reinforce the teaching that the nurse has initiated. The nurse should provide the initial teaching and evaluate the client's learning.

A. Coordinate the team and the plan of care. B. Order durable medical equipment for the client's home. C. Help the client obtain financial assistance. D. Perform a dietary assessment.

Correct Answer is D

Explanation

Choice A reason: This is not the correct choice because this action is not the nurse's responsibility. Coordinating the team and the plan of care is the role of the case manager or the social worker, who can facilitate communication and collaboration among the different disciplines involved in the client's care.

Choice B reason: This is not the correct choice because this action is not the nurse's responsibility. Ordering durable medical equipment for the client's home is the role of the occupational therapist or the physical therapist, who can assess the client's functional needs and abilities and recommend the appropriate devices.

Choice C reason: This is not the correct choice because this action is not the nurse's responsibility. Helping the client obtain financial assistance is the role of the social worker or the financial counselor, who can identify the client's eligibility and options for funding and insurance coverage.

Choice D reason: This is the correct choice because this action is the nurse's responsibility. Performing a dietary assessment is part of the nursing process and the scope of practice of the nurse, who can evaluate the client's nutritional status and needs and provide education and counseling on diet modifications and interventions.

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A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Nursing Test Bank

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